Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space.
Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this paper introduced problems found in HIE by two reports: one from the Office of the National Coordinator and another from experts at the Oregon Health & Science University. Tracing the causes of these problems is necessarily somewhat speculative, but the research helps to confirm impressions I have built up over the years.

The ONC noted that developing HIE is very resource intensive, and not yet sustainable. (p. 6) I attribute these problems to the persistence of the old-fashioned, heavyweight model of bureaucratic, geographically limited organizations hooking together clinicians. (If you go to another state, better carry your medical records with you.) Evidence of their continued drag on the field appeared in the report:

Grantees found providers did not want to login to “yet another system” to access data, for example; if information was not easily accessible, providers were not willing to divert time and attention from patients. Similarly, if the system was not user friendly and easy to navigate, or if it did not effectively integrate data into existing patient records, providers abandoned attempts to obtain data through the system. (pp. 76-77)

The Oregon researchers in the AHRQ webinar also confirmed that logging in tended to be a hassle.

Hidden costs further jacked up the burden of participation (p. 72). But even though HIEs already suck up unsustainable amounts of money for little benefit, “Informants noted that it will take many years and significantly more funding and resources to fully establish HIE.” (p. 62) “The paradox of HIE activities is that they need participants but will struggle for participants until the activities demonstrate value. More evidence and examples of HIE producing value are needed to motivate continued stakeholder commitment and investment.” (p. 65)

The adoption of the Direct protocol apparently hasn’t fixed these ongoing problems; hopefully FHIR will. The ONC hopes that, “Open standards, interfaces, and protocols may help, as well as payment structures rewarding HIE.” (p. 7) Use of Direct did increase exchange (p. 56), and directory services are also important (pp. 59-60). But “Direct is used mostly for ADT notifications and similar transitional documents.” (p. 35)

One odd complaint was, “While requirements to meet Direct standards were useful for some, those standards detracted attention from the development of query-based exchange, which would have been more useful.” (p. 77) I consider this observation to be a red herring, because Direct is simply a protocol, and the choice to use it for “push” versus “pull” exchanges is a matter of policy.

But even with better protocols, we’ll still need to fix the mismatch of the data being exchanged: “…the majority of products and provider processes do not support LOINC and SNOMED CT. Instead, providers tended to use local codes, and the process of mapping these local codes to LOINC and SNOMED CT codes was beyond the capacity of most providers and their IT departments.” (p. 77) This shows that the move to FHIR won’t necessarily improve semantic interoperability, unless FHIR requires the use of standard codes.

It’s bad enough that core health care providers–hospitals and clinics–make little use of HIE. But a wide range of other institutions who desperately need HIE have even less of it. “Providers not eligible for MU incentives consistently lag in HIE connectivity. These setting include behavioral health, substance abuse, long-term care, home health, public health, school-based settings, corrections departments, and emergency medical services.” (p. 75) The AHRQ webinar found very limited use of HIE for facilities outside the Meaningful Use mandate, such as nursing homes (Long Term and Post Acute Care, or LTPAC). Health information exchange was used 10% to 40% of the time in those settings.

The ONC report includes numerous recommendations for continuing the growth of health information exchange. Most of these are tweaks to bureaucratic institutions responsible for promoting HIE. These are accompanied by the usual exhortations to pay for value and improve interoperability.

But six years into the implementation of HITECH–and after the huge success of its initial goal of installing electronic records, which should have served as the basis for HIE–one gets the impression that the current industries are not able to take to the dance floor together. First, ways of collecting and sharing data are based on a 1980s model of health care. And even by that standard, none of the players in the space–vendors, clinicians, and HIE organizations–are thinking systematically.

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space.
Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Given that Office of the National Coordinator for Health Information Technology (ONC) received 564 million dollars in the 2009 HITECH act to promote health information exchange, one has to give them credit for carrying out a thorough evaluation of progress in that area. The results? You don’t want to know.

There are certainly glass-full as well as glass-empty indications in the 98-page report that the ONC just released. But I feel that failure dominated. Basically, there has been a lot of relative growth in the use of HIE, but the starting point was so low that huge swaths of the industry remain untouched by HIE.

Furthermore, usage is enormously skewed:

In Q2 2012, for example, three states (Indiana, Colorado, and New York) accounted for over 85 percent of total directed transactions; in Q4 2013, five states (Michigan, Colorado, Indiana, New York, Michigan, and Vermont) accounted for over 85 percent of the total. Similarly, in Q2 a single state (Indiana) accounted for over 65 percent of total directed transactions; in Q4 2013, four states (California, Indiana, Texas, and New York) accounted for over 65 percent of the total. (p. 42)

This is a pretty empty glass, with the glass-full aspect being that if some states managed to achieve large numbers of participation, we should be able to do it everywhere. But we haven’t done it yet.

Why health information exchange is crucial

As readers know, health costs are eating up more and more of our income (in the US as well as elsewhere, thanks to aging populations and increasing chronic disease). Furthermore, any attempt to stem the problem requires coordinated care and long-term thinking. But the news in these areas has been disappointing as well. For instance:

Patient centered medical homes (PCMH) are not leading to better outcomes. One reason may be the limited use of health information exchange, because the success of treating a person in his own habitat depends on careful coordination.

Insurers are suffering too, because they have signed up enormous numbers of sick patients under the Affordable Care Act. The superficial adoption of fee-for-value and the failure of clinicians to achieve improvements in long-term outcomes are bankrupting the payers and pushing costs more and more onto ordinary consumers.

With these dire thoughts in mind, let’s turn to HIE.

HIE challenges and results

The rest of this article summarizes the information I find most salient in the ONC report, along with some research presented in a recent webinar by the Agency for Healthcare Research and Quality (AHRQ) on this timely topic. (The webinar itself hasn’t been put online yet.)

The ONC report covers the years 2011-2014, so possibly something momentous has happened over the past year to change the pattern. But I suspect that substantial progress will have to wait for widespread implementation of FHIR, which is too new to appear in the report.

You can read the report and parse the statistics until you get a headache, but I will cite just one more passage about the rate of HIE adoption in order to draw a broad conclusion.

What I find notable in the previous quote is that all the things where HIE use improved were things that clinicians have always done anyway. There is nothing new about sending out discharge summaries or reporting test results. (Nobody would take a test if the results weren’t reported–although I found it amusing to receive an email message recently from my PCP telling me to log into their portal to see results, and to find nothing on the portal but “See notes.” The notes, you might have guessed, were not on the portal.)

One hopes that using HIE instead of faxes and phone calls will lower costs and lead to faster action on urgent conditions. But a true leap in care will happen only when HIE is used for close team coordination and patient reporting–things that don’t happen routinely now. One sentence in the report hints at this: “Providers exchanged information, but they did not necessarily use it to support clinical decision-making.” (p. 77) One wonders what good the exchange is.

In the AHRQ webinar, experts from the Oregon Health & Science University reported results of a large literature review, including:

HIE reduces the use lab and radiology tests, as well emergency department use. This should lead to improved outcomes as well as lower costs, although the literature couldn’t confirm that.

Disappointingly, there was little evidence that hospital admissions were reduced, or that medication adherence improved.

Two studies claimed that HIE was “associated with improved quality of care” (a very vague endorsement).

In the next section of this article, I’ll return to the ONC report for some clues as to the reasons HIE isn’t working well.

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Back in March 0f 2013, six health IT vendors came together to announce the launch of the CommonWell Health Alliance. The group, which included Cerner, McKesson, Allscripts, athenahealth, Greenway Medical Technologies and RelayHealth, said they were forming the not-for-profit organization to foster national health data interoperability. (Being a cynical type, I immediately put it in a mental file tagged “The Group Epic Refused To Join,” but maybe that wasn’t fair since it looks like the other EHR vendors might have left Epic out on purpose.)

Looked at from some perspectives, the initiative has been a success. Over the past couple of years or so, CommonWell developed service specifications for interoperability and deployed a national network for health data sharing. The group has also attracted nearly three dozen HIT companies as members, with capabilities extending well beyond EMRs.

And according to recently-appointed executive director Jitin Asnaani, CommonWell is poised to have more than 5,000 provider sites using its services across the U.S. That will include more than 1,200 of Cerner’s provider sites. Also, Greenway Health and McKesson provider sites should be able to share health data with other CommonWell participants.

While all of this sounds promising, it’s not as though we’ve seen a great leap in interoperability for most providers. This is probably why new interoperability-focused initiatives have emerged. Just last week, five major HIT players announced that they would be the first to implement the Carequality Interoperability Framework.

The five vendors include, notably, Epic, along with athenahealth, eClinicalWorks, NextGen Healthcare and Surescripts. While the Carequality team might not be couching things this way, to me it seems likely that it intends to roll on past (if not over) the CommonWell effort.

Carequality is an initiative of The Sequoia Project, a DC-area non-profit. While it shares CommonWell’s general mission in fostering nationwide health information exchange, that’s where its similarities to CommonWell appear to end:

* Unlike CommonWell, which is almost entirely vendor-focused, Sequoia’s members also include the AMA, Kaiser Permanente, Minute Clinic, Walgreens and Surescripts.

* The Carequality Interoperability Framework includes not only technical specifications for achieving interoperability, but also legal and governance documents helping implementers set up data sharing in legally-appropriate ways between themselves and patients.

* The Framework is designed to allow providers, payers and other health organizations to integrate pre-existing connectivity efforts such as previously-implemented HIEs.

I don’t know whether the Carequality effort is complimentary to CommonWell or an attempt to eclipse it. It’s hard for me to tell whether the presence of a vendor on both membership lists (athenahealth) is an attempt to learn from both sides or a preparation for jumping ship. In other words, I’m not sure whether this is a “game changer,” as one health IT trade pub put it, or just more buzz around interoperability.

But if I were a betting woman, I’d stake hard, cold dollars that Carequality is destined to pick up the torch CommonWell lit. That being said, I do hope the two cooperate or even merge, as I’m sure the very smart people associated with these efforts can learn from each other. If they fight for mindshare, it’d be a major waste of time and talent.

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Unbeknownst to me, and perhaps some of you as well, Epic has been charging customers data usage fees for quite some time. The EMR giant has been quietly dunning users 20 cents for each clinical message sent to a health information exchange and $2.35 for inbound messages from non-Epic users, fees which could surely mount up into the millions if across a substantial health system. (The messages were delivered through an EMR module known as Care Everywhere.)

To me, this announcement is troubling in several ways, including the following:

Charging fees of this kind smacks of a shakedown. If a hospital or health system buys Epic, they can’t exactly back out of their hundreds-of-millions-of-dollars investment to ensure they can share data with outside organizations.

Forcing providers to pay fees to share data with non-Epic customers penalizes the customers for interoperability problems for which Epic itself is responsible. It may be legal but it sure ain’t kosher.

In a world where even existing Epic customers can’t share freely with other Epic customers, the vendor ought to be reinvesting these interoperability fees in making that happen. I see no signs that this is happening.

If Epic consciously makes it costly for health systems to share data, it can impact patient care both within and outside, arguably raising costs and increasing the odds of care mistakes. Doing so consciously seems less than ethical. After all, Epic has a 15% to 20% market share in both the hospital and ambulatory enterprise EMR sector, and any move it makes affects millions of patients.

But Epic’s leadership is unrepentant. In fact, it seems that Epic feels it’s being tremendously generous in letting the fees go. Here’s Eric Helsher, Epic’s vice president of client success, as told to Becker’s Hospital Review: “We felt the fee was small and, in our opinion, fair and one of the least expensive…but it was confusing to our customers.”

Mr. Helsher, I submit that your customers understood the fees just fine, but balked at paying them — and for good reason. At this point in the history of clinical data networking, pay-as-you-go models make no sense, as they impose a large fluctuating expense on organizations already struggling to manage development and implementation costs.

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

In an effort to raise everyone’s spirits during these gloomy days of government shutdowns and health insurance exchange glitches, I thought I’d gather all of the recent comedic coverage about Obamacare and the aforementioned topics into this week’s post. You’ll laugh, you’ll scratch your head, and you might even throw a plate or two against the wall at the utter absurdity of much of what is going on right now. I know I did.

From Saturday Night Live

From Funny or Die

From The Colbert Report

From the Daily Show

(My apologies for the captions. Enlarge to full screen for easier viewing.)